ACP InternistWeekly

In the News for the Week of November 2, 2012

Highlights

Retrospective colonoscopy study suggests women under 70 may be at very low risk for advanced proximal neoplasia

Screening some low-risk women for colorectal cancer using sigmoidoscopy rather than colonoscopy may be safe and effective,
according to a new study. More...

Majority of patients with newly diagnosed metastatic cancer think that chemotherapy may be curative, surveys suggest

A majority of patients with newly diagnosed metastatic lung and colorectal cancer undergoing chemotherapy believe the treatment
might be curative, a study found, although more realistic expectations were associated with patients treated in an integrated
network. More...

Test yourself

MKSAP Quiz: 4-day history of intensely pruritic rash

A 46-year-old woman is evaluated for a 4-day history of an intensely pruritic rash on her face and neck. She started using
a new facial moisturizer about 1 week before the onset of the rash. What is the most appropriate corticosteroid cream for
the rash? More...

Urology

New guidelines from the American Urological Association (AUA) update the diagnosis and treatment of non-neurogenic overactive
bladder in adults, as well as microhematuria, vasectomies and urodynamic testing. More...

High-value, cost-conscious care

Evidence-based performance measures for low-value tests and treatments can help physicians provide high-value care, according
to a new policy paper from ACP. More...

CMS update

Support page for e-prescribing to reopen in November

The Centers for Medicare and Medicaid Services (CMS) will re-open the Quality Reporting Communication Support Page on Nov.
1 to allow individuals and CMS-selected group practices to request a significant hardship exemption for the 2013 e-prescribing
payment adjustment. More...

Highlights

Retrospective colonoscopy study suggests women under 70 may be at very low risk for advanced proximal neoplasia

Screening some low-risk women for colorectal cancer using sigmoidoscopy rather than colonoscopy may be safe and effective,
according to a new study.

Researchers used data from about 10,000 adults age 50 or older who consecutively underwent screening colonoscopy. Overall,
they found that 77% had no neoplasia and 18% had one or more nonadvanced adenomas. Another 4.3% had advanced neoplasias (267
distally, 196 proximally, 30 both) and 0.33% had adenocarcinomas (18 distal, 15 proximal).

Results were published online by the American Journal of Medicine on Oct. 10.

Older patients and men were significantly more likely to have advanced proximal neoplasia. Women who were under 70 had only
a 1.1% risk of advanced proximal neoplasia and if they had no distal neoplasia, that risk dropped to 0.86%. Study authors
concluded that risk of advanced proximal neoplasia is a function of age and gender, and that women under 70 have a very low
risk, especially if they have no distal adenoma.

Given this finding, sigmoidoscopy would be likely to provide a similar yield to colonoscopy for this patient population, the
authors said. Therefore, it could be reasonable to tailor colonoscopy screening and consider using sigmoidoscopy more routinely
for women under age 60 or 70. Adding sensitive fecal occult blood testing could potentially make this an even more effective
strategy, as could identification of other risk factors to guide screening.

Use of sigmoidoscopy has declined in the U.S., and improvements in training and reimbursement might be required, given the
benefits that this study and others have shown, the authors said.

However, they cautioned that the current study was limited by being extrapolated data from colonoscopies, rather than actual
sigmoidoscopes. Nonspecialists might not always succeed in reaching the proximal descending colon with a sigmoidoscope, they
noted. Future research should validate these findings and further assess the benefits, risks and costs of modifying screening
practices.

Majority of patients with newly diagnosed metastatic cancer think that chemotherapy may be curative, surveys suggest

A majority of patients with newly diagnosed metastatic lung and colorectal cancer undergoing chemotherapy believe the treatment
might be curative, a study found, although more realistic expectations were associated with patients treated in an integrated
network.

Researchers applied data from the national Cancer Care Outcomes Research and Surveillance study to find out whether and why
patients with metastatic disease thought chemotherapy might be curative in intent. Professional interviewers surveyed about
10,000 patients with newly diagnosed stage IV lung or colorectal cancer nationwide from four to seven months after diagnosis.

Overall, 69% of patients with lung cancer and 81% of those with colorectal cancer who completed the survey responded that
they thought chemotherapy might be curative.

Patients who reported higher scores for physician communication were less likely to provide accurate responses. A score of
80 to 99 resulted in less likelihood of an accurate response compared to a score of less than 80 (OR, 1.37; 95% CI, 0.93 to
2.02) and a perfect communication score of 100 resulted in less likelihood compared to a score of less than 80 (OR, 1.90;
95% CI, 1.33 to 2.72; P=0.002 for the overall comparison).

Education, functional status and the patient's role in decision making were not significantly associated with the belief in
curative potential.

"The observed association between inaccurate beliefs about the likelihood of cure and higher ratings of physician communication
suggests a link between physicians' communication behaviors and patients' understanding of treatment benefits," researchers
wrote. "This suggests that patients perceive physicians as better communicators when they convey a more optimistic view of
chemotherapy. Similarly, the finding that patients, especially those with colorectal cancer, who were treated in integrated
networks were somewhat more likely to understand that chemotherapy is not curative suggests that providers may be able to
improve patients' understanding if they feel it is part of their professional role."

An editorial commented that the disconnect is likely a result of several factors, from doctors having trouble with delivering news of a
terminal diagnosis to patients not believing it.

"This is not one hard conversation for which we can muster our courage but a series of conversations over time from the first
existential threat to life," the editorial stated. "We recommend stating the prognosis at the first visit, appointing someone
in the office to ensure there is a discussion of advance directives, helping to schedule a hospice-information visit within
the first three visits, and offering to discuss prognosis and coping ("What is important to you?") at each transition."

Test yourself

MKSAP Quiz: 4-day history of intensely pruritic rash

A 46-year-old woman is evaluated for a 4-day history of an intensely pruritic rash on her face and neck. She started using
a new facial moisturizer about 1 week before the onset of the rash. She has stopped using the moisturizer, but the rash has
persisted. She has treated the rash with calamine lotion without improvement. Medical history is otherwise unremarkable, and
she takes no medications.

On physical examination, she has poorly defined, red, weepy, eczematous-appearing patches on the cheeks and neck. A few fine
vesicles, along with some serous crusting, are seen within the rash.

Which of the following is the most appropriate corticosteroid cream for this rash?

Urology

New guidelines from the American Urological Association (AUA) update the diagnosis and treatment of non-neurogenic overactive
bladder in adults, as well as microhematuria, vasectomies and urodynamic testing.

The guidelines appeared online Oct. 23 at the AUA's website.

Regarding overactive bladders, proper diagnosis requires at minimum a careful history, physical exam and urinalysis to document
symptoms and signs that characterize overactive bladder and exclude other disorders, the guidelines said. Next, a urine culture and/or post-void residual assessment may be performed and information from bladder diaries and/or
symptom questionnaires may be obtained.

Urodynamics, cystoscopy and diagnostic renal and bladder ultrasound should not be used in the initial workup of an uncomplicated
patient.

First-line treatments include behavioral therapies such as bladder training, bladder control strategies, pelvic floor muscle
training and fluid management. They can be combined with anti-muscarinic therapies.

Clinicians should avoid using anti-muscarinics in patients using other medications with anti-cholinergic properties, in patients
with open-angle glaucoma or in frail patients.

Third-line treatments include FDA-approved methods such as sacral neuromodulation or peripheral tibial nerve stimulation in
patients with severe refractory symptoms or those ineligible for second-line treatments and who are willing to undergo a surgical
procedure.

A non-FDA-approved method includes intradetrusor onabotulinumtoxinA in patients willing to return for frequent post-void residual
evaluation and perform self-catheterization. Augmentation cystoplasty or urinary diversion for severe, refractory, complicated
patients may be considered.

Indwelling catheters are not recommended.

AUA released three other guidelines as well.

The guideline for the diagnosis, evaluation, and follow-up of asymptomatic microhematuria is geared toward primary care physicians as well as urologists. It updates an earlier "best practice" document from the AUA,
including a reduction in the number of urinalyses required to determine need for evaluation, preferred radiological imaging
and follow-up.

The AUA guideline on vasectomy reviewed 284 articles published from 1949 to 2011 and is targeted to vasectomy providers.

The AUA guideline on urodynamic testing for common lower urinary tract symptoms is intended to assist clinicians in the appropriate selection of urodynamic tests.

Cardiology

Cardiopulmonary exercise testing appears to be safe in patients with high-risk cardiovascular diseases, according to a new
study.

Researchers performed a single-center retrospective review of cardiopulmonary exercise testing in a heterogeneous cohort of
high-risk patients to determine its safety in this population. A total of 5,060 exercise tests in 4,250 unique patients were
included. The primary end point of the study was occurrence of major adverse events during exercise testing. Results were published online Oct. 22 by Circulation.

Symptom-limited exercise testing was completed in most patients (94.5%), who stopped because of fatigue, dyspnea or chest
pain. Testing was stopped in the remaining 5.5% because of patient request, electrocardiogram changes, abnormal blood pressure
response or major adverse event.

A total of 1,192 patients (24%) were found to have a peak VO2 below 14 mL/kg/min, indicating severe functional impairment. The rate of adverse events during cardiopulmonary testing was
0.16%, most commonly ventricular tachycardia (six of eight events). No patients died during testing.

The authors noted that although many of the disorders present in their study population are usually considered contraindications
to exercise testing, adverse event rates were low, and none occurred in patients with hypertrophic cardiomyopathy, pulmonary
hypertension or aortic stenosis.

They also said that cardiopulmonary exercise testing is the recommended method for determining cardiovascular disability but
is usually not done in high-risk patients because of safety concerns. Their study, they said, should help change that practice.

The results have limited generalizability because the study was performed at only one center, and data on disease severity
were not available for all study participants, among other limitations, the authors wrote.

They also stressed that all of the patients in their study had established cardiovascular diagnoses, that tests were carefully
performed at an experienced tertiary care center, and that some patients with severe forms of cardiac disease should never
undergo exercise testing.

However, they wrote, "for other patients with these disorders, [cardiopulmonary exercise testing] appears to be reasonably
safe and can serve as a helpful aid in the management of these patients." Further study in a larger population is needed to
determine which patients have the greatest risk of an adverse event during testing, they concluded.

High-value, cost-conscious care

Evidence-based performance measures for low-value tests and treatments can help physicians provide high-value care, according
to a new policy paper from ACP.

The paper discusses two categories of low-quality interventions: those in which harms exceed benefits, and those with an undesirable
tradeoff between benefits and expenditures, as determined by a multi-stakeholder group after quantitative assessment.

Types of measures that can be used to evaluate these interventions include direct measures, which judge whether an intervention
was of low value based on each patient's unique clinical circumstances, and indirect measures, which evaluate utilization
rates, the paper said. The paper also discusses the evidence base for creating performance measures for low-value services,
individual versus group-level performance measurement, and applying performance measures to improve value.

"The first step in addressing the high cost of health care should be decreasing use of interventions that provide no or very
little benefit and are of low value," the paper said. "Performance measures for low-value care need to be developed and tested
with the same rigorous methods as for performance measures for underuse of services; however, the evidence based used to develop
measures will differ substantially. Evidence-based performance measures for low-value services can help motivate physicians
to provide high-value care to their patients."

The policy paper was published Oct. 30 by Annals of Internal Medicine and is available online.

CMS update

Support page for e-prescribing to reopen in November

The Centers for Medicare and Medicaid Services (CMS) will re-open the Quality Reporting Communication Support Page on Nov.
1 to allow individuals and CMS-selected group practices to request a significant hardship exemption for the 2013 e-prescribing
payment adjustment.

Those who wish to submit a significant hardship request should do so via the Quality Reporting Communication Support Page on or between Nov. 1, 2012 and Jan. 31, 2013. CMS will review requests on a case-by-case basis, and all decisions will be
final.

This applies to the 2013 payment adjustment only. Hardship exemption requests for the 2014 payment adjustment will be accepted
later in 2013.

More information on the e-prescribing payment adjustment is also available online.

Those with questions about the e-prescribing incentive program and payment adjustments or those who need help submitting a
hardship exemption request can contact the QualityNet Help Desk at 866-288-8912 (TTY 877-715-6222) Monday through Friday from
7:00 a.m. to 7:00 p.m. CST, or via e-mail. Additional information and resources are available at the CMS website.

MKSAP Answer and Critique

The correct answer is D: Hydrocortisone valerate. This item is available to MKSAP 16 subscribers as item 4 in the Dermatology
section.

MKSAP 16 released Part A on July 31. More information is available online.

Because this patient's rash involves the face and neck, the lower potency corticosteroid hydrocortisone valerate is the safest
choice. This patient likely has an allergic contact dermatitis to her moisturizer. Appropriate choice of a topical corticosteroid
requires consideration of both the nature of the skin disease and the anatomic site being treated. Adverse effects of topical
corticosteroids can include thinning of the skin, development of striae and hypopigmentation, and when used chronically, development
of telangiectasia. Anatomic areas that are at particular risk of complications from topical corticosteroids include the face
(particularly around the eyes, where skin is very thin) and any occluded areas of skin, such as the axillae, inguinal folds,
and under pendulous breasts and the abdominal pannus. Lower potency corticosteroids are best used in these areas to minimize
the risk of complications. Patients should be taught to use an adequate amount of corticosteroid to treat the affected skin;
however, they should be encouraged to use it only as long as is necessary.

Clobetasol propionate is an ultrapotent corticosteroid, and both betamethasone dipropionate and desoximetasone are high-potency
corticosteroids. Their routine use on the face and in other high-risk areas is not recommended.

Key Point

High-potency topical corticosteroids cause thinning of the skin and should be avoided on the face, in intertriginous skin
folds, and on atrophic skin where absorption may be enhanced.

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